US Healthcare Claims Adjudication – Senior Process
Associate

Job Title

Senior Process Associate

Experience Required

4 – 6 Years

Timing
6:30 pm - 3:30 am
Job Summary

We are looking for an experienced US Healthcare Claims
Adjudication Specialist with strong knowledge in end-to-end claims processing
and payer guidelines. The candidate will be responsible for adjudicating
medical claims accurately while ensuring compliance with CMS, HIPAA, and
client-specific policies.

Key Responsibilities
Perform
end-to-end US healthcare claims adjudication.
Verify
member eligibility and benefits based on Date of Service (DOS).
Apply
CPT, ICD-10, HCPCS, and payer adjudication rules accurately.
Process
authorization, corrected, and duplicate claims.
Handle
COB (Coordination of Advantages) and multi-insurance claims processing.
Review
and manage denials, appeals, and claim reprocessing activities.
Calculate
deductibles, copay, coinsurance, and out-of-pocket responsibilities
accurately.
Identify
non-covered services, exclusions, accident claims, and policy limitations.




Ensure
compliance with CMS, HIPAA, and payer guidelines.
Maintain
productivity, quality, and turnaround time as per SLA requirements.
Coordinate
with internal teams and stakeholders for issue resolution and escalations.
Participate
in process improvement initiatives and audits.

Required Skills
Robust
knowledge of US healthcare claims adjudication process.
Good
understanding of CPT, ICD-10, HCPCS, and medical terminology.
Experience
in handling commercial, Medicare, and Medicaid claims.
Knowledge
of denials management and appeals processing.
Familiarity
with payer policies and insurance guidelines.
Solid
analytical and problem-solving skills.
Good
communication and interpersonal skills.
Proficiency
in MS Office and claims processing systems.

Eligibility Criteria
Any
Graduate.
4 – 6
years of relevant experience in US Healthcare Claims Adjudication.
Experience
in handling h

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